Cluster Randomized Trial Examining the Impact of Automated Best Practice Alert on Rates of Implantable Defibrillator Therapy.

Abstract

Background Implantable cardioverter-defibrillators (ICDs) are indicated in patients with left ventricular ejection fraction ≤35%, but many eligible patients do not receive this therapy. In this cluster randomized trial, we investigated the impact of a best practice alert (BPA) through the electronic health records on the rates of electrophysiology referrals, ICD implantations, and all-cause mortality in severe cardiomyopathy patients. Methods and Results Providers in the Heart and Vascular Institute (n=106) and in General Internal Medicine (n=89) were randomized to receive or not receive a BPA recommending consideration for ICD implantation. Patients belonging to the BPA and no BPA groups of providers were followed to the end points of electrophysiology referrals, ICD implantations, and all-cause mortality. Between 2013 and 2015, patients with reduced left ventricular ejection fraction were managed by 93 providers in the BPA (n=997 patients) and 102 providers in the no BPA (n=909 patients) groups. Patients in the 2 groups had comparable baseline characteristics. After a median follow-up of 36 months, 638 (33%) patients were referred to electrophysiology, 536 (27%) received an ICD, and 445 (23%) died. Patients in the BPA group were more likely to be referred to electrophysiology (hazard ratio=1.23; P=0.026), to receive ICD therapy (hazard ratio=1.35; P=0.006), and exhibited a trend towards slightly lower mortality (hazard ratio=0.85; P=0.091). Conclusions Delivering a BPA through the electronic health record recommending to providers consideration of ICD implantation when the left ventricular ejection fraction is ≤35% improves the rates of electrophysiology referrals and ICD therapy in patients with severe left ventricular dysfunction.

• Authors: Jae Lee, Libby Szeto, Deepak Kumar Pasupula, Aliza Hussain, Anam Waheed, Shubash Adhikari, Michael Sharbaugh, Floyd Thoma, Andrew D Althouse, Gary Fischer, Joon Sup Lee, Samir Saba
• Journal: Circulation. Cardiovascular quality and outcomes (Circ Cardiovasc Qual Outcomes) Vol. 12 Issue 6 Pg. e005024 (06 2019) ISSN: 1941-7705 [Electronic] United States
• PMID: 31181957 (Publication Type: Journal Article, Randomized Controlled Trial, Research Support, Non-U.S. Gov't)

Topics

• Adult
• Aged
• Aged, 80 and over
• Cardiomyopathies (diagnostic imaging, mortality, physiopathology, therapy)
• Cause of Death
• Death, Sudden, Cardiac (prevention & control)
• Defibrillators, Implantable
• Electric Countershock (instrumentation)
• Electronic Health Records
• Female
• Humans
• Male
• Middle Aged
• Pennsylvania
• Prospective Studies
• Referral and Consultation
• Reminder Systems
• Risk Assessment
• Risk Factors
• Stroke Volume
• Treatment Outcome
• Ventricular Dysfunction, Left (diagnosis, mortality, physiopathology, therapy)
• Ventricular Function, Left
• Young Adult